Children Who Snore – Do they have Sleep Apnea?
Iman Sami, M.D.Division of Pulmonary and Sleep Medicine,
Children’s National
June 3, 2015
• Describe the spectrum of sleep disordered breathing (SDB) in healthy children
• Describe Nocturnal Polysomnography (PSG)• Describe phenotypes and diagnosis of obstructive sleep apnea (OSA)
• Discuss sequelae and treatment options of OSA
Objectives
• Bed‐time problems• How long a child takes to fall asleep• Quantity • Quality• Sounds
Sleep History
• Spectrum of repetitive episodes of complete or partial obstruction of the airway during sleep.
• “Hark, how hard he fetches breath.” ― William Shakespeare, King Henry IV, Part 1
Sleep Disordered Breathing
• No significant obstructive events, arousals, or gas exchange abnormalities
• Often noticed while family is on vacation and sharing a room with child
• 10‐12 % of children
Primary Snoring (PS)
• Increasingly negative intra‐thoracic pressures during inspiration that lead to arousals and sleep fragmentation
• Events may not meet scoring criteria for obstructive apnea or hypopnea
• Gas exchange unaffected
Upper Airway Resistance Syndrome (UARS)
• Prolonged partial or complete upper airway obstruction
• Disrupts normal ventilation and gas exchange• Disrupts normal sleep• 1‐4% of children
Obstructive sleep apnea (OSA)
Pathophysiology of OSA
Marcus, CL Pathophysiology of OSAS in Children. Sleep and Breathing in Children,A developmental approach. Marcel Dekker Inc, 2000
• “Heroic” snorts • Asynchronous movements of chest & abdomen
• Witnessed apnea • Disturbed sleep • Sweating• Enuresis
When snoring is reported:
• Behavioral problems• Academic concerns• Excessive daytime sleepiness• Mouth‐breathing• Recurrent adeno‐tonsillitis
Other red flags
• Cannot distinguish with certainty between primary snoring and obstructive sleep apnea
• Clinical suspicion is high ‐‐‐Referral for a PSG
Despite taking a good history
Revised AAP Clinical Practice Guidelines (2012) ‐ Diagnosis of OSA• All children/adolescents should be screened for snoring
• PSG should be performed if OSA is suspected• If not available, then specialist evaluation with an alternative test recommended
Marcus et al, PEDIATRICS Vol. 130, No. 3, Sept 2012
AASM Practice Parameters
• Recommend PSG – suspected OSA in children (S)• Nap ‐ not recommended (O)• Insufficient data for unattended in‐home portable PSG testing
• PSG indicated in children considered for Tonsillectomy and Adenoidectomy (T & A) (G) to establish the severity of OSA, (postoperative risk) and need for a repeat PSG after surgery
Aurora RN, et al Sleep. 34:379‐388 2011
Otolaryngology guidelines (2011)
• PSG ‐most reliable and objective test to assess presence and severity of OSA,
• PSG is not necessary to perform routinely to diagnose SDB
Roland, PS et al Otolaryngol Head Neck Surg July 2011 vol. 145 no. 1 suppl S1‐S15
• Requests are screened and prioritized • Pediatric Sleep Lab ‐ caters to infants, children and teenagers with “space” for parent
• Location ‐ inpatient• Staff – child‐friendly, ratio of tech to patient is high
• Capnography• Severe studies – priority in scoring and interpretation
Pediatric Sleep Lab
Polysomnography Recordings
From I Sami & J Owens, Polysomnography for the Pediatric Pulmonologist, Diagnostic Tests in Pediatric Pulmonology, 1st Ed. 2014
BASELINE POLYSOMNOGRAPHY REPORT
• Signals recorded: • Methodology: • Patient Information• Reason for referral: • Study Summary• History: • Medications Reported: • Sleep Staging and Architecture: EEG • Respiratory findings: RDI (includes all apneas, hypopneas and RERAs). The AHI
(includes all respiratory events except RERA’s) • Oxygenation and ETCO2: • Limb Movement findings: • EKG findings:• Impression/Recommendations: • Final Diagnosis:
Hypnogram
• Hypoventilation – Maximum end‐tidal carbon dioxide > 54 mmHg– End‐tidal carbon dioxide > 50 mmHg for more than 25 %
of TST
• Sleep Fragmentation – Increased EEG arousals ‐ >10/hr– Increased awakenings
Obstructive Apnea
Obstructive Hypopnea
Central Apnea
Obstructive Apnea
Obstructive Hypopnea
Central Apnea
• Mild OSA ‐ AHI > 1.5 or AI > 1 /hour • Moderate OSA ‐ AHI is >5, • Severe OSA – AHI > 10. • Hypoxemia
– Oxygen desaturation nadir < 91%– Change in oxygen nadir from baseline > 3%
PSG diagnostic criteria for OSA
• Hypoventilation: – Maximum end‐tidal carbon dioxide > 54 mmHg– End‐tidal carbon dioxide > 50 mmHg for more than 25 % of TST
• Sleep Fragmentation:– Increased EEG arousals ‐ >10/hr– Increased awakenings
PSG diagnostic criteria for OSA
• 4 year old• History: Snores, poor appetite, has wheezed with URIs,
• Mouth‐breathes during sleep with head extended
• Pre‐school told his parent he should be evaluated for “ADHD”.
Case I
• Physical Exam: • Weight < 3%, length 10‐25%• Adenoidal facies with allergic shiners• Cervical lymph nodes: ++• Rest of exam unremarkable except:
Case I
• Most common cause is Adeno‐tonsillarHypertrophy
• Strong association between OSA, and asthma
Type I OSA
• 12 year old – snores very loudly so siblings do not want to share a room
• Has asthma with worsening control in last 3‐4 years despite ICS and leukotriene modifier
• Academic performance: poor, sometimes falls asleep in class, always in the car
• Teased by other kids
Case II
• BMI – 34, large neck circumference• Edematous nasal turbinates, • Narrow palate, tonsils: 2+• End‐expiratory wheezing on lung examination
Case II
• Major risk factor: Obesity • Morning headaches• Co‐morbidities:
– Allergic rhinitis– Asthma – Hyperglycemia– Hypertriglyceridemia
Type II OSA
• Serum HCO3 and hematocrit• Imaging• EKG• Echocardiogram• Pulmonary Function Tests
Other Investigations
• Strong association between SDB and: –Behavior ‐ hyperactivity, inattention, & aggression
–Cognition – IQ, memory, academic performance and executive functioning
Cognitive and Behavioral Consequences of OSA
Gozal D. Pediatrics. 102 (3 Pt 1):616‐620 1998Bourke R, et al. Sleep Med. 12 (5):489‐496 2011
• Mechanisms: Sleep fragmentation and intermittent hypoxemia impact prefrontal cortex
• Window of vulnerability in developing children
• Treatment interventions may only partially reverse deficits
Cognitive and Behavioral Consequences of OSA
Gozal D, et al. Pediatrics. 107 (6):1394‐1399 2001
Metabolic & Cardiovascular Consequences of OSA
From D Gozal Metabolic Consequences of SDB, Principles & Practice of Pediatric Sleep Medicine, 2nd Ed. 2014
• It’s not just the AHI ‐• Impact on the child’s wellbeing • Mild cases: trial of anti‐inflammatory therapy ‐montelukast and nasal steroids
• Orthodontal procedures • Moderate and severe cases – surgical treatment and/or positive airway pressure
You have the report – what next?
Goldbart AD, et al. Pediatrics. 130 (3):e575‐e580 2012Villa MP, et al. Sleep Breath. 15 (2):179‐184 2011
• Adeno‐tonsillectomy ‐ first‐line treatment of patients with adeno‐tonsillar hypertrophy
• High‐risk patients ‐monitored postoperatively • Postoperative evaluation • Intranasal corticosteroids ‐mild OSA• Weight loss ‐ in patients who are overweight or obese.
Revised AAP Clinical Practice Guidelines (2012) ‐Management of OSA
Marcus et al, PEDIATRICS Vol. 130, No. 3, Sept 2012
• Up to 27% • Risk factors:
– Obesity – Asthma – High AHI– GERD – Down’s syndrome – CP
Persistence of OSA post T & A
Bhattacharjee R, et al. Am J Respir Crit Care Med. 182 (5):676‐683 2010
• Continuous positive airway pressure ‐ if adeno‐tonsillectomy not performed or OSA persists postoperatively.
Revised AAP Clinical Practice Guidelines (2012) ‐Management of OSA
Marcus et al, PEDIATRICS Vol. 130, No. 3, Sept 2012
Treatment Options
• Mask‐fitting • CPAP after a protocol of desensitization
• Titration study • BiIevel PAP if pressures high or hypoventilation
• Pulmonary and sleep colleagues in the Division of Pulmonary and Sleep Medicine, CNHS
Acknowledgements